Public Health Software Program for Medical Patient Data Tracking, Situational Awareness and Services Rendered During Major Response Events PURPOSE Provides information on a software program developed in-house by the Hidalgo County Health and Human Services Department (HCHHSD) in Texas to track patient flow, medications dispensed, and services rendered during Operation Lone Star characterized as one of the largest humanitarian events in the United States. SUMMARY There are very few tailored software products that are economically feasible and available to local health departments tasked with responding during local emergency response events that potentially involve the need to track patients, identify services rendered, quantify medications dispensed, and all be available in real-time for decision makers and support staff in the Emergency Operations Center. This Best Practice reviews a system developed by the Hidalgo County Health and Human Services Department used during the largest humanitarian event in the United States called Operation Lone Star. The system allows for real-time large scale patient information sharing between the first responders at the POD sites, Emergency Operations Center, and facilitates overall tracking of services, resources balancing, and provides a centralized data source of patient information being assessed in a large scale operation. DESCRIPTION Rigoberto Hinojosa, Director of Operations for the Hidalgo County Health and Human Services Department initially began development of a software program to be used for public health response efforts in 2007 for Operation Lone Star 2007. The system has continued to be modified and improved every year since and enhancements are now being evaluated for the event next year in 2012. Although the software program was primarily designed to be used during the large Operation Lone Star yearly events in South Texas, the system can be modified and adapted for other events and has been successfully used for drive-thru influenza vaccination events and smallpox response exercises. HIDALGO COUNTY HEALTH AND HUMAN SERVICES Hidalgo County is located in the deep southern portion of Texas and is bordered by Mexico on the south. The 2010 population is estimated at approximately 774,769. The Page 1 of 27 pages
county seat is located in Edinburg while the largest city in Hidalgo County is McAllen. Other communities of interest in Hidalgo County are Weslaco, Pharr, Mission, and San Juan. Hispanics, Germans, and Anglo-Americans are the three larges ethnic groups. The labor force that has made Hidalgo County a prosperous agricultural region is also made up of one of the poorest in the nation. Of all the counties in Texas, Hidalgo has the most colonias. As a county-based health jurisdiction, Hidalgo County Health and Human Services Department (HCHHSD) has a long history of serving as a leader and model with regard to public health emergency preparedness efforts in South Texas. Public health preparedness in Hidalgo County is attributable to its ability to successfully practice and evaluate public health response measures through its continual planning, training, exercises, and evaluation in addition to responding to real-life actual events each year with hurricanes. OPERATION LONE STAR 2011 Operation Lone Star 2011 is a two-week event and is a joint medical services project that unites the State of Texas Health and Human Services agencies, the United States Public Health Service (USPHS), Texas Military Forces, county health departments, local service providers and partners, school districts and civilian volunteers in the largest public health humanitarian effort in the country to provide free medical services to the community. Operation Lone Star is a real-time, large-scale emergency preparedness exercise that provides medical service and disaster recovery training to state agencies and local personnel while addressing the medical needs of thousands of underserved Texas residents. OLS provides a great opportunity for the military, public health, and partnering civilian and governmental agencies to practice working together in the event of an emergency or disaster. The Operation Lone Star 2011 event had PODs set up over a 2 week period in at least 6 different cities stretching across the deep South Texas area from Brownsville in the southernmost part of Texas up to Laredo which is more than 200 miles away along the Texas-Mexico border. However, the focus of this Best Practice Report occurred in two smaller cities within Hidalgo County situated in between the two most distant cities noted above. Hidalgo County Health and Human Services Department conducts Operation Lone Star during week one with two POD s. Page 2 of 27 pages
SITUATIONAL AWARENESS Situational awareness is critical when you need the ability to identify, process, and comprehend the critical elements of information within the response environment and how this could be impacting your team and mission. Effectively utilizing and communicating those elements will dictate how successful you will be in maintaining control of the event. In stressful events, situational awareness can be dynamic, hard to maintain, and unfortunately easy to lose. Operation Lone Star tracking software was designed to give the Hidalgo County Health and Human Services Department Operations staff in the Emergency Operations Center a more comprehensive service picture of the dynamics occurring at the POD level. HCHHSD also maintained situational awareness occurring at both sites through the development of a SQL program designed to track patient flow totals, medical services received, referrals given, immunizations administered, pharmacy prescriptions filled, and counts for other services provided (e.g. # eye exams, # hearing tests, # diabetic screenings, # behavioral health assessments, etc). The statistical information was constantly changing and providing real-time information for EOC staff monitoring the events in the support center. TRACKING PROCESS Optimizing patient flow is critical to ensuring safe, efficient care. The Operation Lone Star medical data tracking system was developed by Information Technology personnel working directly for the Hidalgo County Health and Human Services Department. The practice management software is 100% web-based, meaning staff can use it at anytime and any location where internet service is available. Data is backed up securely every few minutes as the system is operating. Secured copies are stored every night and every backup is verified to restore correctly. The database system is used for tracking clients by scanning bar code wrist bands in the POD applied as clients arrived and tracking them through the various screening and medical stations in the POD. The data from the scanning of individual client tags is immediately entered into a central server where it can be viewed at an individual POD site, the Emergency Operations Center, or other sites granted access in a summary format. All Operation Lone Star data can be viewed on Web EOC. Daily or cumulative totals are provided for: Diabetic Screening Hearing & Vision Screening Medical Services Vaccine Doses Administered Poison Control Eye Screening Service Heart Disease Information Clients Immunized Nutritional Diabetic Education Smoking Cessation Page 3 of 27 pages
Registration began promptly at 8:00 a.m. each day and concluded at 5:00 pm at each POD site and the basic client flow thru the POD system was essentially the same at each site. A bar coded wrist band was placed on every individual using any OLS service and scanned to populate the number of registered clients. As clients entered the lobby waiting area, EMTs and Paramedics performed visual triage to detect clients with evidence or visible signs of possible communicable illness. These were segregated, scanned with a temporal thermometer for temps over 100.4 and received indicated PPE. Individuals with signs of illness were banded and fast- tracked for secondary triage and a more thorough medical evaluation. The wrist band was marked with a unique number and bar code to facilitate tracking client progress through check-points and at key service locations to capture utilization numbers. A final exit scan was done to check the client out of Operation Lone Star. At exit the medical record folder was collected and filed by the POD staff. Important documents such as school physicals and prescriptions were to remain with the client. The wrist band scanning process captured the entrance, progress and exit of the client by time stamping each step. Managed groups of clients moved from the lobby waiting area into client intake where a second bar code scan occurred and a folder of registration, interview, screening and physical record and consent forms was issued. Bilingual interviews were conducted to record health history and concerns. Before referral for additional medical services, screening measurements of vital signs, blood sugar, height, weight and BMI were determined. While waiting for screening services and before clients were directed to medical services, clients could even visit with a veterinarian, veterans affairs, and educators on diabetes, heart health, smoking cessation, diet and nutrition. Once initial screening was completed, wristbands were scanned a third time and clients were escorted or directed to immunizations, medical services, mental health and counseling, social services, pharmacy, hemoglobin (anemia screening), vision, hearing, additional educational opportunities and referrals. Adults, infants and children were stopped at the vaccination suite for immunization status, counseling and administration of indicated vaccines. Clinic intake staff accessed existing records through the State ImmTrac system. Evaluations by physical, mental and emotional health specialists were available at no charge. Hemoglobin determination was by referral and prescriptions of select drugs were filled on site. Providers offered evaluation or assistance with a wide variety of specialized services including school Page 4 of 27 pages
physicals, vision, hearing, low cost prescription resources, Texas-211 evacuation and special needs registration, and contact information for low cost health care. At end of the final station, the client checked out, the wrist band was scanned and all clinic documents were retrieved. The wrist band scanning process captured the entrance, progress and exit of the client by time stamping each step. SOFTWARE USER SETUP AND PATIENT FLOW for OPERATION LONE STAR and CLIENT TRACKING. Software Setup: 1. User/volunteer logs into the client tracking software. Page 5 of 27 pages
2. User selects a site to be working at or an activity to perform. Page 6 of 27 pages
3. The software user then selects the optional services to be provided at their assigned workstation. Each individual POD site has a screen for easy access in the main data capturing elements for more detailed information. The Icons below will access current data for numbers of patients arriving, numbers of registered clients and registration wait times, screening referrals and times, number and types of child and adult vaccines as well as captured times spent in the immunization section, diagnoses counts for both adult and child patients, pharmacy medication counts prescribed, medical services provided (e.g. diabetic screening, eye screening, hearing screening, etc), and service exit tracking to identify total time spend in the clinics during OLS. Page 7 of 27 pages
CLIENT FLOW THRU THE POD: 1. Client enters the POD at the initial check-in location of the facility. 2. A tyvek wrist band with a pre-printed barcode ID number is attached to the client s wrist and scanned to start the tracking process. Tyvek pre-printed barcodes used for tracking patients and services rendered. Page 8 of 27 pages
3. The wrist band is then scanned to document the arrival of the client at Operation Lone Star. 4. Client then goes to the general waiting area before being called into the registration area where they will receive a client folder and demographics are collected. 5. Wrist band is scanned into the client registration section of the software. Page 9 of 27 pages
6. Client fills out required paperwork at the registration table. 7. Wrist band is scanned to generate matching labels for the documentation. Page 10 of 27 pages
8. Wrist band is scanned upon exiting the registration area to provide total time spent in the registration area. Bottleneck delays are examined all along the entire flow process to expedite patient flow. 9. Client proceeds through the other available screening services (e.g. diabetic screening, vitals screening, hemoglobin testing, etc). Each service can scan the barcode label if sufficient workstations are available. Some screening services are required (e.g. Vitals) whereas other services are optional for the clients. Page 11 of 27 pages
10. Client exits available screening services and all services received are check off on the screening exit software module. 11. If the client is receiving immunizations, client proceeds to immunization waiting area. Page 12 of 27 pages
12. The client is then called to enter immunization area and ID Bracelet is scanned. Page 13 of 27 pages
13. Client receives immunization(s) and ID bracelet is scanned on exit and immunization(s) received are selected on the immunizations module of the software. (This in and out data will provided us with the average time a client spends receiving an immunization). 14. If the client is receiving medical services, the client proceeds to the medical services waiting area. Page 14 of 27 pages
15. When the client is called into medical services, the clients ID bracelet is scanned only once regardless of the number or types of medical services being received. (This will provide us with a count of clients receiving medical services). Hidalgo County does have the option however of more specific tracking of medical services rendered if needed and have done so in prior operations but for Optional Lone Star 2011 this option was not exercised. 16. Upon receiving medical services client leaves medical services and proceeds to the pharmacy or to the exit. Page 15 of 27 pages
17. If the client goes to the pharmacy, the clients ID bracelet is scanned at arrival and the prescriptions are taken by the pharmacist. 18. Pharmacist fills the prescriptions that can be filled on site. 19. Pharmacist provides the client with the filled prescriptions and the unfilled prescriptions. Page 16 of 27 pages
20. The client s ID bracelet is scanned again on exit and the medications dispensed and those not dispensed are documented in the pharmacy module. (This information provides us with the amount of time a client is spending at the pharmacy, what prescriptions were filled and which were not. The prescription information is helpful in developing the formulary for the following year s Operation Lone Star.) 21. Client proceeds to additional screening services and social services (if any) available. Page 17 of 27 pages
22. Client proceeds to the exit after completing all screening services available. The id bracelet is scanned at exit and any additional services received are entered into the exit module of the software. This information provides us with an average amount of time a client is spending at Operation Lone Star. Page 18 of 27 pages
23. After the client leaves, additional information from their chart can be entered into the software, such as diagnosis, to allow pertinent personnel to look for trends or statistics necessary to prepare for the following year. Page 19 of 27 pages
REPORTING The reports section of the software allows for real time data to be viewed at the POD site, Emergency Operations Center or even the State Operations Center to provide the individuals with the most up to date information. The Daily Reports provided EOC Operations with a quick view in real time of the numbers of patients entering the facilities, number of services being requested and provided, and the number of referrals given. When tracking inventories, this becomes a very useful tool to ensure adequate supplies are being requested and delivered in a timely manner. Client Counts: The Client Count report gave a quick overview of the numbers of patients being seen at each site in real-time as well as the number of the patients leaving without registering. In some cases, patients would want a particular service (e.g. dental) that was not being provided and would leave prior to registering and officially entering the POD facility. Page 20 of 27 pages
Client Wait Times: Client Wait Times could be compared by POD sites to give EOC Operations more situational awareness with the flow of patients and make adjustments to POD operations as needed to minimize as much as possible the time required to complete registration, prescription filling, immunization delivery, and total time in the clinics. Staffing and volunteer resources could be adjusted as needed between POD sites and cities as needed. Page 21 of 27 pages
Immunizations administered for all sites (report is also available on a per site basis): The Vaccines Administration Page gave immediate access to the numbers and types of vaccines being administered in real time at the POD sites. These counts could be compared to the resupply orders being requested by the individual POD sites for next day planning purposes. Page 22 of 27 pages
Diagnosis count for all sites (report is also available on a per site basis): The Diagnoses Count screen was not used for real-time data collection during Operation LoneStar 2011 due to a shortage of volunteers used to collect the data. However, it could be used retrospectively if the Department chooses to perform a record review and capture this info for next year s planning purpose. Page 23 of 27 pages
Individual Site Reports Screening Services Counts: Service counts in real time for each POD were tracked to determine the levels of service being requested by patients entering the POD sites. POD Incident Commanders and leaders have immediate access to all their data and services being rendered in real time operation. The EOC or Unified Command can view individual sites and their specific data or can view an overall operation conglomerate of all sites participating in the operation to produce an overall operation picture of the event in real-time and maintain situational awareness across large jurisdictions. Page 24 of 27 pages
Pharmacy Counts: Pharmacy counts were available in real-time to track specific medications being dispensed in-house as well as a total accounting for all medications prescribed. This gave Operations a clear indication of the medicinal issues being seen by the attending physicians and provided additional planning intel each day as the event progressed. Page 25 of 27 pages
BENEFITS The process to capture information was essentially seamless. The data was real-time. The software operates on a SQL server and is 100% web-based meaning you can use anytime and anywhere you have internet access. No extra resources were needed to update or maintain the PCs. Reporting capability can grow as needed. Differences in service times at different POD sites can be easily evaluated. Provides pharmacy leadership capability by measuring work accomplished. Data is backed up securely approximately every 10 minutes, with secure copies and a full backup stored every night. Built from the ground up using no cost, open source, supportable software maintained by existing IT staff. There are daily, weekly, monthly, and yearly views. System tracks pharmacy prescriptions filled in-house as well as prescriptions prescribed but not filled. Area Command or other command centers can easily access the information for planning purposes if granted access. Program can be expanded, improved upon, with existing internal IT staff. System not limited by the number of PODs. Scalable to any number of POD sites. System can be used from any site location since it is web-based. For example, Laredo, Texas which is 2 + hours (180 miles) away from Hidalgo County used the system during week 2 of Operation Lone Star 2011. System is easily adaptable for multiple jurisdictions. Page 26 of 27 pages
RESOURCES H1N1 FULL SCALE EXERCISE PLANNERS, TRAINERS and EVALUATORS Hidalgo County Health and Human Services Disaster Preparedness and Response 1302 South 25th Avenue Texas Extension Engineering Service Edinburg, Texas 78539 The Texas A&M University System Point of Contact: 301 Tarrow Eduardo (Eddie) Olivarez, Health Director College Station, TX 77840-7896 Rigoberto (Rigo) Hinojosa, Director of Operations Point of Contact: Phone: (956)-383-6221 Gary Meaney, Training Manager Phone: 979-458-0857 DISCLAIMER Lessons Learned Information Sharing (LLIS.gov) is the Department of Homeland Security/Federal Emergency Management Agency's national online network of lessons learned, best practices, and innovative ideas for the emergency management and homeland security communities. The Web site and its contents are provided for informational purposes only, without warranty or guarantee of any kind, and do not represent the official positions of the Department of Homeland Security. For more information on LLIS.gov, please email feedback@llis.dhs.gov or visit www.llis.gov. Page 27 of 27 pages